Crypto 99 Conference Registration Form -- Instructions at Bottom

Last Name:   _______________________________________

First Name:  _______________________________________

Address:     _______________________________________

             _______________________________________

             _______________________________________

Affiliation: _______________________________________

Phone:       _______________________________________

Fax:         _______________________________________

Email:       _______________________________________

URL:         _______________________________________

Sex (M/F):   _______________________________________

CONFERENCE REGISTRATION -- Choose 1, 2 or 3:

1. Full Time Student ($230) ......................... US$ _______

2. Attended Eurocrypt '99 (Prague) ($415) ........... US$ _______

3. Regular Registration Fee ($495) .................. US$ _______

4. IF YOUR REGISTRATION IS POSTED AFTER JULY 17, 1999,
   ADD $75: ......................................... US$ _______

ROOM AND BOARD -- (no smoking, 4 nights, Sunday to Thursday;
   breakfast and lunch Monday to Thursday)

5a. Single Room ($250) .............................. US$ _______

5b. Double Room ($190 per person) ................... US$ _______
    -- ROOMMATE'S NAME: ____________________________
6. Saturday Night ($70 single/$50 per person double)  US$ _______

7. Thursday Night ($70 single/$50 per person double)  US$ _______

Extra Guest Attendance for the Social Program only:
8. ($130 per person) GUEST NAME: ___________________  US$ _______

9. TOTAL FUNDS DUE (US DOLLARS): .................... US$ _______

Payment - checks IN US DOLLARS DRAWN ON A US BANK made payable
to "U.C. Regents", or by credit card:

Credit Card Type:  __ American Express   __ Visa   __ MasterCard
Card Number: ___________________ Expiry Date: _____________
Name on card: __________________ Cardholder's Signature: _________

10. (Check if applicable) I do NOT want to be an IACR member _____

11. (Check if applicable) I do NOT want my details published _____

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INSTRUCTIONS:

Please type or print clearly.

If you specified a double room, please provide the name of
your roommate.

* Instructions for line #10:

When you register and pay for Crypto you will automatically become
a member of IACR for the next calendar year free of charge.  As a
member next year you will receive the IACR (email) Newsletter and
The Journal of Cryptology.  If you do NOT want to be a member next
year, and do NOT want to receive the Journal or Newsletter, check
(X) the box on line #10.

* Instructions for line #11:

The personal contact information that you provide is maintained
in the IACR Membership Database and will be published in the
conference attendees list and the IACR Membership List that is
sent to all members every year.  It is NOT made available to any
other organization in electronic form.  If you do NOT want your
contact information to be published in the conference attendee
list and the IACR Membership List, check (X) the box on line #11.


* How to submit the completed form:

Send the completed form and payment to:

  Crypto Conference
  Campus Conference Services
  University of California
  Santa Barbara, CA 93106-6120

You can also FAX the form to +1 805-893-7287,
or send it by EMAIL to  iacrmem@iacr.org .

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